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A to Z: A Compliance Dictionary

March 12, 2024

Today, we’re taking you to compliance school. Don’t worry, there won’t be a test, so no need to study! 

Sometimes compliance can be complicated, and with so many specific words, it’s easy to feel overwhelmed.

At Abyde, we believe in simplifying compliance, so we’re kicking it back to Kindergarten – more specifically, the ABCs. Here are the ABCs of compliance – see how many you already know! 

Audit – An audit is an examination of how compliant your practice currently is. The random HIPAA audit program will likely resume this year.  

Business Associate – A Business Associate is someone who handles Protected Health Information (PHI) and performs functions on behalf of a Covered Entity (both defined on this list!). Business Associates include a variety of fields, like medical equipment manufacturers, medical marketing teams, disposal companies, and more. 

Covered Entity – A Covered Entity directly works with sensitive patient data. This includes healthcare providers, health plans, and clearinghouses. 

Disaster Recovery Plan – A Disaster Recovery Plan is a required set of procedures to handle the effects of an unexpected event. This includes identifying potential risks, like different natural disasters, and more.  

Electronic Protected Health Information – Electronic Protected Health Information, or ePHI for short, is any PHI that is created, received, maintained, or transmitted in electronic form.  

Fraud – Fraud is deception to obtain something of value. HIPAA is in place to protect patients and prevent fraud by securing patient information and if these regulations are broken, there are consequences.  

GDPR – The GDPR, or General Data Protection Regulation, is essentially a HIPAA equivalent for our friends across the pond, or the European Union. The GDPR includes more than just healthcare, but does define the privacy of patient records. 

HIPAA – HIPAA, the thing you probably have heard of at least a million times (at least I know I have), or the Health Insurance Portability and Accountability Act, signed into law in 1996, protect the privacy and security of individuals’ health information and to establish standards for the electronic exchange of health information.

Incident Response – An incident response is how you handle a situation. Under HIPAA, remember to document everything and report it in a timely manner. 

Joint Commission – Joint Commission is an accreditation agency that evaluates healthcare organizations. Joint Commission would be considered a Business Associate if they come into contact with Protected Health Information. 

Know your Patient – Know Your Patient, or KYP, is a way to identify a patient before any information is shared with the wrong person. 

Logs – Logs are prevalent in HIPAA and OSHA, and are just documentation. This includes things like asset logs, or documentation of the items your practice has, and things like a breach log, which includes an explanation of a breach (who, what, where, when, etc.)

Minimum Necessary Standard – The minimum necessary standard is the protocol that the least amount of sensitive information about a patient should be shared.

Notice of Privacy Practices – The Notice of Privacy Practices is a required notice to patients on how their information will be used and shared. 

OSHA – OSHA, or the Occupational Safety and Health Administration, is the government agency that ensures safe and healthy working environments for workers. 

PHI – Protected Health Information, or PHI, is identifiable information about a patient that is created and shared by a Covered Entity or Business Associate. This includes names, social security numbers, emails, medical record numbers, and more.  

Quality Management – Quality Management is the constant need to improve and monitor current processes and how to optimize patient care, employee safety, and more. Overall, how you can make your organization better for all involved. 

Ransomware – Ransomware is a form of malware that holds data for ransom, requiring practices to pay a ransom for access to PHI. 

Security Rule – The Security Rule is a component of HIPAA and sets the standard for all of the necessary safeguards a practice must have in place to protect PHI. 

Training – Training is the continuous learning and improvement of all employees (including the owner) of compliance regulations.

Update Information – Updating information is very important in compliance, ensuring all information is up-to-date about your practice is key. For instance, have employees leave? Make sure you make a note of that in your policies and roles. With the Abyde software, we do that for you! 

Vulnerability Assessment – A Vulnerability assessment is a way to test cyber security frameworks to ensure that your system is secure. 

Whistleblower – A whistleblower is someone who calls out violations of compliance. Whistleblowers are to be protected and make our healthcare systems a safer place. 

X-ray Safety – X-ray safety precautions are vital, like any use of equipment. For instance, make sure proper protective equipment is worn, use shielding, and be aware of the position of the device. 

Yearly Risk Assessment – A Yearly Risk Assessment is a thorough evaluation of your practice’s compliance. With Abyde, we ask these questions throughout the year, ensuring your practice is compliant if you’re doing the right thing!

Zero tolerance – There is Zero tolerance for breaking HIPAA or OSHA legislation. 

Whew! This one might have been a little bit longer than our traditional ABCs, but they’re all so important to keeping our patients and staff safe.


To learn how you can keep your practice or business compliant, reach out to info@abyde.com or schedule a consultation here for Covered Entities, and here for Business Associates.

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What OSF Healthcare’s Ransomware Fine Teaches Every Practice About SRAs

August 5, 2026 Penelope Schweitzer No comments yet

August 5, 2026 The latest HIPAA fine is another clear reminder that ransomware attacks are, unfortunately, here to stay in the healthcare industry. A settlement involving the OSF Healthcare System was recently announced by the Office for Civil Rights (OCR). As an enterprise healthcare provider in the midwest, the organization serves 174 locations, including 16 hospitals – a prime target for a ransomware attack.    So, what happened?  In April 2021, OSF discovered that they joined the unlucky club of ransomware victims when a malicious actor deployed Nephilim, a ransomware strain made to target larger organizations. Once the ransomware infected OSF systems, the hacker demanded payment or patient Protected Health Information (PHI) would be leaked online. In this attack, sensitive information like financial account information, driver’s license numbers, medical record numbers, and more, were all exposed. Over 53,000 patient records were exposed in this attack.  When ransomware attacks in healthcare have soared 278% in recent years, it’s more of a when then an if your organization doesn’t have the right safeguards in place.  While the breach was discovered in April, OSF healthcare reported the breach to the OCR in October. The OCR took it from there, digging into what precautions (or lack thereof) let this happen.  What did the OCR discover? If you’ve read any of our other fine breakdowns, you already know where this is going: another missing Security Risk Analysis (SRA).  The SRA is a required document every HIPAA-regulated entity (ie: every practice and their Business Associates that handle patient information) needs to complete. The SRA is a thorough review of the physical, technical, and administrative safeguards in place to prevent PHI ending up in the wrong hands. While the OCR didn’t specify exactly how the ransomware got into OSF’s system, a technical safeguard vulnerability was very likely the entry point. A proactive SRA could have flagged that gap before it turned into a major breach. In addition to missing this required documentation, OSF also took too long to report the breach to the OCR and notify affected patients. This is a direct violation of the Breach Notification Rule, which requires organizations to notify patients within 60 days of a discovered breach. Moreover, since the breach impacted more than 500 patients, OSF was also required to report this breach to the OCR within 2 months as well. Time is of the essence in every component of a breach, from securing systems to ensuring affected parties are aware to protect themselves and an over five month delay was unacceptable in the eyes of the OCR.    What was the result?  OSF’s settlement tops the list as the largest fine of the year, coming in at $552,250, plus government monitoring for the next two years.  It’s very important to note that this breach occurred in 2021, meaning that over five years were spent from the initial breach, to investigations, to the public press releases. Also, the average cost of a healthcare breach is over 7 million dollars –  from implementing secure systems, notifying patients, legal fees, and more. The Takeaway While the settlement payment and Corrective Action Plan (CAP) are just the cherries on top, this experience was a tremendous cost of time, money, and resources, highlighting the importance of making sure everything is secure before a situation occurs.  So, when was the last time you looked at your SRA? It’s time to seriously analyze your current compliance posture. Ransomware groups don’t check whether you’re a small dental office or a 16-hospital health system before they attack, they check whether the door was left open. Time and again, OCR’s findings come back to the same root cause: organizations can’t secure what they haven’t even identified as a problem. Looking to review your current compliance standings? Meet with our team of experts for a complimentary educational consultation. 

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June 19, 2026   Quick Guide:  The Office for Civil Rights issued a major fine towards Spencer Gifts benefits plan. This fine reinforces that all HIPAA-regulated entities must have a thorough compliance program.    The Stats You Need to Know 76%: The percentage of large healthcare breaches now caused by hacking/IT incidents. $450,000: Financial settlement of this enforcement. 10,023: The number of individuals were impacted in this breach.  264%: The increase in ransomware-related breaches reported to the OCR since 2018.   When you think about Spencer’s, you likely picture the staple mall store with pop culture novelty gifts, not the latest HIPAA settlement enforcement headline.  Spencer Gifts LLC Flexible Benefits and Welfare Benefit Plans, or their employee benefits plan, reached a settlement with the Office for Civil Rights for $450,000 and a 2 year Corrective Action Plan (CAP).  This fine is a reminder that Covered Entities include all parties that create and utilize patient data, including health care plans. While they might not see patients traditionally, they still are responsible for keeping Protected Health Information (PHI) secure.    What Happened?   In response to employee complaints regarding access to their employee benefits portal, Spencer Gifts Health Plan discovered their systems were infiltrated with ransomware in November 2021. Malicious actors encrypted over 10,000 individuals’ PHI and demanded a ransom. The exposed data included names, phone numbers, social security numbers, and more, putting employees at risk.  The breach was reported in January 2022. After years of investigation, it was settled that the plan failed to meet basic HIPAA Security Rule requirements proactively.    The Compliance Gaps A common misconception is that an organization faces a financial penalty due to a breach. While the breach serves as the catalyst for the investigation, the OCR is looking to see if an organization has a thorough compliance program in place and made a genuine effort to protect patient data.  For instance, the health plan did not complete a Security Risk Analysis (SRA). This required assessment identifies all technical, administrative, and physical safeguards (and vulnerabilities) across your organization. By completing this document, your organization can address concerns before they become an issue. There’s no way to know where risks are unless they are properly reviewed.  Additionally, the plan did not have sufficient policies and procedures, nor trained staff adequately. Without sufficient policies and training, staff are left without the tools to recognize and respond to HIPAA threats before they escalate. As a result, Spencer Gifts now faces $450,000 in penalties and two years of government monitoring to ensure those missing requirements are finally implemented. And that figure doesn’t account for the years of investigation, legal fees, breach notification costs, and operational disruption that preceded the settlement.   The Biggest Takeaway This case isn’t only a lesson for retail organizations’ health plans, but it’s a warning for every HIPAA-regulated entity. The OCR can and will investigate any organization exposed for failing to meet HIPAA requirements, including small medical practices To be prepared before a cyberattack occurs, make sure your organization has: A completed and current Security Risk Analysis. A trained workforce that knows how to handle PHI Accessible policies and procedures staff can actually reference. An up-to-date compliance program.  Ready to strengthen your compliance program? Schedule a free educational consultation with our team today.

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May 4, 2026   Quick Guide:  The Office for Civil Rights (OCR) just issued a massive wake-up call, announcing four simultaneous settlements totaling $1,165,000. The Stats You Need to Know 76%: The percentage of large healthcare breaches now caused by hacking/IT incidents. 427,000+: Total number of patients impacted across these four recent settlements. 264%: The increase in ransomware-related breaches reported to the OCR since 2018. The Office for Civil Rights (OCR) just announced a flurry of investigation settlements. At the root of the four that were announced: ransomware. Ransomware attacks continue to target healthcare facilities. As of last year, the OCR discovered that 76% of large breaches are due to hacking and IT shortcomings. Unfortunately, healthcare information is a goldmine for hackers, exposing sensitive data that can lead to identity theft, financial fraud, and compromised patient care. Breakdown & Lessons Learned Regional Women’s Health Group (Axia) The first settlement was regarding the Regional Women’s Health Group (Axia), an OBGYN network across five states. In this case, the organization submitted a breach report following a cyberattack that exposed over 37,000 patients. The settlement resulted in a $320,000 fine and a 2-year Corrective Action Plan (CAP). The Lesson: The OCR didn’t just fine them for being hacked; they reached a settlement because the healthcare organization failed to conduct a “thorough and accurate” Security Risk Analysis (SRA). If you don’t know where your vulnerabilities are, you can’t patch them. Unfortunately, hackers counted on this negligence and exploited it.  Assured Imaging This was the largest of the four fines, affecting a staggering 244,813 individuals. When a ransomware infection hit their servers, Assured Imaging, a medical imaging enterprise, reported a breach to the OCR. After a long investigation (the initial cyberattack occurred in 2020), and resulted in a $375,000 settlement and a 2-year CAP.  The Lesson: Beyond the initial ransomware attack, it was discovered that Assured had never completed an SRA. Additionally, the organization did not notify patients within 60 days of discovery of the breach. This is a direct violation of the Breach Notification Rule, which aims to allow patients to take control and mitigate risks as quickly as possible.  Consociate Health Consciate Health is the only Business Associate (BA) fine in the four. BAs continue to be under the OCR’s microscope, such as potentially needing to follow stricter requirements when handling patient data. Their breach started with a phishing attack that eventually led to the encryption of systems holding data for over 136,000 people. The BA discovered the ransomware six months after the initial phishing attack. Upon the OCR’s further investigation, the SRA was found to be insufficient. The organization paid a $225,000 settlement and entered into a 2-year CAP.  The Lesson: Human error (phishing) is the most common entry point for ransomware. Constant employee training is just as important as a strong firewall. Additionally, just because a BA doesn’t directly work with patients doesn’t mean it isn’t their responsibility to keep patient data secure.  SG Health Plan Even employee benefit plans are regulated under the Health Insurance Portability and Accountability Act (HIPAA). SG Health Plan, associated with a Connecticut energy provider, reported that the data of 9,316 members were exposed following a ransomware attack. It was discovered that the organization did not complete an extensive SRA. The benefit plan entered a settlement with the OCR for $245,000 and a 2-year CAP.  The Lesson: This settlement highlights that HIPAA applies to corporate health plans just as much as it does to traditional healthcare providers. Additionally, every organization that handles Protected Health Information (PHI) must complete an SRA.  The Bottom Line The OCR isn’t fining practices for ransomware attacks, but for being ill-prepared.  However, it is easier said than done to ensure your organization is secure in protecting patient data and complying with HIPAA.  Proactively implementing the HIPAA Security Rule is your opportunity to mitigate the impacts of a cyberattack. Waiting until the ransom note appears on your screen is a million-dollar mistake. Want to see what you might be missing?  Run a 5-Minute HIPAA Gap Assessment and protect your practice today! 

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